1. NYU Medical Grand Rounds Clinical Vignette Pavan Bhatraju MD, PGY-II June 19, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 72 year old male who presented with dyspnea on exertion and fatigue for the last 3 weeks. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Prior to this presentation he had not seen a doctor for the last 5 years. He first noticed his symptoms of dyspnea on exertion and shortness of breath 3 weeks prior and the symptoms have continued to progress. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: DM HTN Stage II CKD Social History: 40 pack tobacco smoking history, no alcohol Family History: No family history of cancer Allergies: None Medications: Aspirin 81 mg daily Glyburide 2.5 mg daily Lisinopril 40 mg daily Simvastatin 10 mg at night U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: thin adult male, lethargic Vital Signs: T:38.6 BP:130/90 HR:90 RR:12 HEENT – pale conjunctivae, dry mucous membranes Remainder of Physical Exam was Normal. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Laboratory Findings CBC: Hemoglobin – 8.5 g/dL, Mean corpuscular volume 76 fl. Red blood cell distribution width 16.5% Remainder of CBC was within normal limits Basic Metabolic panel BUN 45 mg/dL, - Creatinine 1.8 mg/dL Remainder of BMP was within normal limits Hepatic Panel: Within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Iron-Deficiency Anemia –Gastrointestinal –Dietary Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Patient was referred to gastroenterology for a diagnostic colonoscopy. Outpatient Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Outpatient Course Colonoscopy biopsies were positive for adenocarcinoma. Kras mutation positive. CT scan of the abdomen and pelvis with IV and oral contrast Cecal mass with mesenteric lymphadenopathy and hepatic metastases U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Immediately after diagnosis the patient was started on palliative chemotherapy with FOLFOX –Leucovorin Calcium –Fluorouracil –Oxaliplatin After 4 cycles of chemotherapy with FOLFOX the patient had a repeat CT scan of the abdomen that showed disease progression. Outpatient Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Chemotherapy was changed to FOLFIRI with bevacizumab: –Leucovorin Calcium –Flurouracil –Irinotectan Hydrochloride –Bevacizumab After 5 doses of chemotherapy, a repeat CT scan of the abdomen showed further progression of disease. Chemotherapy was changed to FFG –Leucovorin Calcium –Flurouracil –Gemcitabine Disease Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. After 2 cycles of FFG the patient was admitted to the medical intensive care unit with neutropenic sepsis. He died 8 months after diagnosis. Disease Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Metastatic Adenocarcinoma of the Colon Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS